Aims and objectives of service
This service provides specialist short term care and rehabilitation support, including nursing and therapy in the community, to help people to recover from an acute illness and to regain their independence. It also identifies long term care needs and aims to help people recover more quickly from illness and prevent avoidable deterioration through active intervention.
It aims to avoid hospital admissions, and premature admission to long-term care, and it helps people to be as independent and active as possible for as long as possible. It supports timely hospital discharges and reduces the length of stay once a patient no longer requires hospital treatment.
Working collaboratively with the Care Co-ordination Team based at Nottingham University Hospitals and the Urgent Care Co-ordinators they will respond to referrals within two hours. All people accepted by the service will be assessed within 48 hours of transfer to the service.
The team has an effective and efficient skills mix including: Physiotherapists; Occupational Therapists; nurses including Rehabilitation Nurses; Assistant Practitioners; Community Care Officers (social care); Rehabilitation Support Workers and Mental Health Nurses.
All staff within the service have the appropriate skills to support people with mild to moderate organic mental health needs (dementia) as part of the core service to support dedicated Mental Health Practitioners within the team.
The service trains carers and other support staff to recognise the symptoms of the common causes of illness that often result in avoidable hospital admissions, e.g. constipation, urinary tract infection and chest infections.
The service follows CSCI regulations and cannot admit people being actively treated for alcohol or drug related issues.
Days/hours of operation
The service is available between 8am and 10pm Monday to Friday excluding Bank Holidays and between 8am and 5pm on weekends and Bank Holidays. Clinical advice and support is available between 5pm and 8am, every day of the year.
The service accepts referrals from the Health & Care Point triage service. The service operates an open referral system for: adults who have a physical health or care need and/or an organic mental health need; those aged 65 years and over with a functional mental health need and people who do not require acute medical care but cannot be supported in their own home.
The service is available to anyone registered with an NHS Nottingham City Clinical Commissioning Group (CCG) GP practice. County CCG residents can be admitted at the discretion of the service to support health community initiatives where capacity allows and recharged to the relevant CCG.
Nursing care assessment or rehabilitation support are provided within a community residential setting to people who are registered with a Nottingham City GP with a physical health or care need and/or an older person’s mental health condition.